Primary Care Coding Alert

Few family practice coders would argue: the more they know about what takes place during an office visit, the better they can do their jobs. "Coders require meticulous and comprehensive documentation so they can assign codes that accurately reflect the breadth and depth of the service provided," comments Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a national healthcare consulting firm specializing in financial and healthcare management with a focus on physician compliance, coding, billing and reimbursement issues based in Lansdale, Pa. Poor documentation often results in incorrect code assignments, which may lead to lower reimbursement on the one hand, or increased risk for fraud and abuse charges on the other.

To encourage better documentation, she says, many practices have created a form or template for progress notes. The forms allow a physician to quickly record the services provided and refer to other documentation in the patient record. The coder can then review the physician's list and determine which level of service should be reported.

The most effective forms, Falbo says, are designed to reflect specifically the clinical focus of the individual practice and follow the sequence of a typical patient encounter. In addition, she advises using the 1995 documentation guidelines (DG) for E/M services because the exam component guidelines are more lenient than the 1997 guidelines and are more conducive to a physician's clinical protocol. The 1995 guidelines focus on organ systems as opposed to the bullets required in the 1997 DGs. "The bullet concept caused more confusion for the physicians and limited their clinical autonomy in examining the patient," she says. "In addition, the newly proposed documentation guidelines that will be implemented soon are based on the 1995 documentation guidelines."

"There is a lot to be said for using standardized templates," Falbo says. "Most family physicians I know have educated themselves about the need for thorough documentation. But when they are seeing a patient, the focus of their attention is patient care, not coding. And that is how it should be. A progress note form can be a valuable tool to help prompt them to consider what needs to be documented about the nature of the presenting problem. It captures crucial, relevant information."

Other coding experts recommend that family practices approach templates with caution. "There is a certain amount of controversy surrounding use of these forms," says Garnet Dunston, CPC, MPC, president and CEO of the coding services firm Dunston Enterprises Inc., in Phoenix, and past secretary for the American Academy of Professional Coders National Advisory Board. "It is relatively simple to check off a list of items on a form. But this might not represent work that justifies a higher level of service."

On the other hand, the process of dictating progress notes and consciously documenting care may provide a better assessment of the level of service. "For instance, it can be easy for the physician to quickly run down the patient's previous history in the chart," Dunston says. "With a template, the physician may check off nearly every item. But did the amount of work done actually justify a higher-level code? It's hard to tell." Many compliance officers, in fact, warn that items on a form are too often completed with little thought, greatly increasing the risk for overbilling.

For practices using a standardized form, the initial section should feature the patient's name and the date of service -- information that should be repeated on each subsequent page of the form. Following these elements should be spaces to note chief complaint (CC) and the history of the present illness (HPI). Room should be left for notations about pertinent characteristics of the patient's symptoms, including: location, quality, severity, duration, timing, context, modifying factors and associated signs and symptoms.

Space should also be left for the physician or ancillary staff to make note of personal, family and social history (PFSH).

"A well-designed form will include a review of systems (ROS) section that will list the 13 body areas  noted in the 1995 documentation guidelines, along with check-off boxes," says Falbo. (See insert, sample #1, (To view this insert please open the PDF file.) "Progress Notes," Review of Systems or for a customized copy call Millennium Healthcare Consulting Inc. at 215-362-5355).

The physician should gather information about the specific symptoms the patient is experiencing in each of the systems. Falbo explains, for instance, the physician may ask about history of fractures, muscle cramping, twitching or pain, weakness, limitations on walking, running or participation in sports, joint swelling or joint stiffness, etc. when reviewing the musculoskeletal system.

Falbo reminds physicians that a check in a box is sufficient for a normal finding, but an abnormal finding must be explained. "The key is to document at least one pertinent review of systems relevant to the chief complaint. In addition, at this point in time, the statement 'all other systems negative or non-contributory' is acceptable to qualify as a comprehensive ROS."

At the end of the history section, Falbo advises that practices add a check-off box with a notation that the patient's medication list was updated. "Updating the medication lists is regarded as one item of the history, and so it is wise to include a prompt on the template to make sure this is done."

The template should also include a box that may be checked if the patient is new and the physician reviewed the health profile completed when the patient arrived for the appointment. "Boxes like these act like a link to other documentation in the chart," Falbo explains. Similar cues verifying physician review of lab results and other tests in the medical record can help coders determine which level of E/M service to report.

Whenever physicians reference another section of the medical record (e.g., medication lists, health history form, etc.), they cannot simply check the item off the progress notes form. They must also sign and date the form to which they are referring, she says.

The next section of the template should be carefully designed, says Falbo. "Although the body parts evaluated during the physical exam are the same as those listed in the ROS, the doctor will go about the exam in a different sequence than the review. The form should follow a logical clinical flow, from head to toe." (See insert, sample #1, (To view this insert please open the PDF file.) "Progress Notes," Physical Exam).

Other coding professionals recommend using a list that more closely follows the 1995 guidelines. (See insert, sample #2 (To view this insert please open the PDF file.) or go to www.aafp.org/fpm/980100fm/progressnote.pdf).

Beneath each item, Falbo adds, the template should include typical findings for the physician to check off. "Under heart, for instance, the form should include items like 'no murmur, rubs or gallops' and 'regular rate and rhythm.' The list should be tailored for the types of indications the physician focuses on. I'd suggest the coding staff work closely with their doctors to make sure the list includes the conditions and comments most common to their practice. This will make documentation much easier and more consistent." In addition, blank spaces should be left so the physician can fill in details not covered elsewhere.

Falbo notes that physicians need only to check off an item if the exam results in normal findings. If an abnormality is discovered, however, the physician must make comments about the abnormality. These comments may be made directly on the progress notes form or, if a template is not used, in the patient's record.

No check-off list can guide medical decision-making (MDM), Falbo points out. She recommends the progress note template leave plenty of space for the physician's comments in this area. "The physician needs to be very specific about relevant findings, particularly in regard to acuity and severity for the appropriate diagnoses. Documentation about the work-up plan and the care plan also needs to be thorough."

At the end of the form, coders should ensure that a notation about how the time was spent is also included. This may be an important consideration if counseling (e.g., discussion about HIV testing results) constitutes greater than 50 percent of the time spent with the patient and thereby influences which level of service may be reported.

"I recommend that the final component of the form include a line to indicate the total amount of time with the patient. Then, there should be a final check-off box that allows the doctor to indicate if more than 50 percent of the visit was spent counseling the patient. If this is the case, physicians need to be certain that they provide detailed documentation about the counseling aspects, like patient education, prognosis, diagnostic results, importance of compliance with chosen management options, risk factor reductions or other topics related to the patient's medical status," Falbo says.